GOLDEN LIVING CENTER - HY-PANA
4545 SHELLEY COURT, STOCKTON, CA 95207
Citation Number: 030004050
Citation Date: 6/27/2007
Violation Date: 7/22/2006
Class: AA
Penalty: $ 80000.00

F-257 The facility must provide comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71-81 degrees Fahrenheit.

F-309 Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being, in accordance with the comprehensive assessment and plan of care.

An unannounced visit was made to the facility on 07/23/06, 07/24/06, 07/31/06, 08/07/06, 08/21/06, 09/25/06, and 11/27/06 to investigate Complaint #CA00087566. The Department determined the facility failed to:

1. Provide Resident A with safe room temperatures when the facility's air conditioning unit malfunctioned on 07/22/06 during an area heat wave. 2. Follow the facility's undated policy "Dangerous Temperature Level" emergency action plan, which addressed measures the facility should have provided during times of increased heat.

These failures resulted in Resident A becoming short of breath and requiring emergency transportation to the general acute care hospital (GACH) on 07/22/06 where, on arrival to the emergency room (ER), Resident A was in full cardiac arrest with CPR (Cardiac Pulmonary Resuscitation) being preformed. CPR was unsuccessful and the resident was pronounced deceased. An autopsy subsequently determined the cause of death to be hyperthermia due to high environmental temperatures.

Resident A was a 79 year old female admitted to the facility on 03/08/05 with diagnoses that included congestive heart failure (a condition where there is ineffective pumping of the heart leading to an accumulation of fluids), emphysema (an accumulations of air in the tissues causing difficulty breathing), high blood pressure, chronic colitis (inflammation of the colon), anxiety, depression, and chronic back pain.

A Quarterly Minimum Data Set (MDS-assessment tool) dated 06/22/06 revealed that the resident had no short or long-term memory problems and she was independent with daily decision-making capabilities and had no difficulties understanding others and others understood her. The MDS also indicated that the resident required extensive assistance with toilet use, personal hygiene, and bathing; limited assistance with bed mobility, transferring, ambulation, and dressing; and was independent with eating (the resident's diet was for no added salt with cut up meat). An ADL (activities of daily living) care plan ("original date" of 03/08/05) updated on 03/26/06 indicated that the resident was working with the facility's RNA (restorative nursing assistant) five times per week and that the resident ambulated using a "straight cane" as tolerated. Resident A was her own responsible party.

Dietary Quarterly Progress Notes dated 06/24/06 indicated that the resident's weight was 55 kg. Based on this weight the resident would require 1650 cc of fluid (55 kg times 30 cc per State Operations Manual Appendix P-Survey Protocol for Long Term Care). There was no documentation indicating the diet Resident A received provided the required amount of fluids.

Resident A had a care plan initiated at admission, which was updated 06/12/06, for nutritional risk related to mechanically/therapeutically altered diet...risks HTN (high blood pressure), congestive heart failure (CHF), taking diuretics, anxiety, depression, significant weight gain over the past six months. The care plan interventions included monitor for signs and symptoms of poor skin turgor, dry mucous membranes, concentrated urine, and elevated temperature.

Resident A's July 2006 Physician's Orders indicated that Resident A was receiving the following medications:

>Lasix 40 mg daily- Lasix is a diuretic (a medication that increases the excretion of urine). >Benicar 40 mg daily-Benicar is for high blood pressure. [According to the 2005 Lippincott's Nursing Drug Guide, under the "interventions" section it recommends to "monitor patient closely in any situation that may lead to a decrease in BP (blood pressure) secondary to reduction in fluid volume-excessive perspiration, dehydration, vomiting, diarrhea, excessive hypotension (low blood pressure) can occur."] >Oxytrol patches two times a week. Oxytrol patches are used to control urinary spasms. [According to the 2006 Lippincott's Nursing Drug Guide, Oxytrol use is contradicted with a diagnosis of colitis (Resident A had a diagnosis of chronic colitis) and should be used cautiously with renal impairment. The drug guide also indicated under the "teaching points" section that Oxytrol could also cause "...decreased sweating (avoid high temperatures: serious complications can occur because you will be heat intolerant)."]

None of the above medication precautions were addressed in Resident A's plan of care.

The Nurse's Notes on 07/22/06 revealed the following:

> At 11:30 a.m. the resident's vital signs were documented as being 96.4 (temperature), 84 (heart rate), 20 (respirations), and 100/60 (blood pressure). > At 2:00 p.m. the resident was documented as being alert and responsive. No vital signs taken. > At 5:00 p.m. documentation indicated the following, "dinner was served assisted with meals ate 15% dinner and drank juice. Encouraged to eat more but she said 'no.'" No vital signs taken. > At 8:00 p.m. the resident was documented as being alert and verbally responsive. No vital signs taken. > At 10:00 p.m. the Nurse's Notes revealed the following, "Resident has short (sic) of breath. HOB (head of bed) elevated to facilitate easy breathing. O2 at 3 L/Min (liters per minute) per N/C (nasal cannula) for SOB (shortness of breath). Called (Physician's name)...He is to call back." No vital signs taken. > At 10:20 p.m. nursing documentation revealed, "(Physician's name) called back and told him that she has short of breath (sic) and pale. A physician order was received to transfer the resident to the hospital. No vital signs taken. >10:30 p.m. nursing documentation continued, "(emergency response company's name) here to transfer Resident..." No vital signs taken.

The EMTs' (Emergency Medical Technicians) documentation dated 07/22/06 indicated that they received the call at 10:36 p.m. and that they arrived at the facility at 10:41 p.m. The EMT documentation indicated that at 10:42 p.m. the resident's pulse was 49, respirations 6 and ineffective, and they were unable to get a blood pressure reading. At 10:55 p.m. the documentation indicated that the resident was pulseless and respirations were absent and the resident's cardiac rhythm was asystole (cardiac standstill or arrest, absence of a heartbeat) and CPR (cardiac pulmonary resuscitation) started.

The GACH's "General Adult Emergency" sheet dated 07/22/06 (documentation from the ER) indicated that the resident arrived at 11:09 p.m. in cardiac arrest. CPR was continued, which was unsuccessful and the resident was pronounced deceased at 11:13 p.m.

On 07/22/06, according to the Interim Administrator (interviewed 08/07/06 at 10:30 a.m.) he called the facility at 7:36 p.m. (per his cell phone record) to see if the facility's power had been disrupted (the Administrator indicated that in some parts of the city power had been disrupted). During the telephone call the nursing staff informed him that the power was still on, however the building seemed "very warm." The Administrator indicated that he informed Licensed Vocational Nurse (LVN) 1 to call the Maintenance Supervisor.

The Maintenance Supervisor stated (interviewed 08/07/06 at 10:45 a.m.) he was called to the facility on 07/22/06 at approximately 8:00 p.m. He indicated he got to the facility between 8:30 and 9:00 p.m. and that the building did feel warm. The Maintenance Supervisor was asked about the temperature in the building, the Maintenance Supervisor stated he did not take temperatures, he just felt the air coming out of the air vents and the air felt warm.

The Maintenance Supervisor indicated that he then went to the air conditioning unit and he observed that the "circulating pump" was not working. He called the air conditioning company the facility used and spoke with a technician who walked him (the Maintenance Supervisor) through some trouble-shooting techniques. The Maintenance Supervisor indicated that he was able to get the air conditioning unit running again. The Maintenance Supervisor indicated that by 11:00 p.m. the air coming from the air vents was cooler and he went home although he took no temperature readings.

The facility's undated (but identified by the Director of Nurses (DON) on 08/21/06 as the current emergency action plan at the time of the incident) "Dangerous Temperature Level" emergency action plan indicated under the introduction section that a dangerous temperature was any temperature "outside the acceptable range for a person's comfort and safety." The plan did not define "acceptable range." The plan did indicate, "'Comfortable and safe' refers to the overall temperature that minimizes the resident's risk of hyperthermia, hypothermia, and susceptibility to respiratory ailments and colds." The plan revealed that the facility staff should immediately notify the medical director or the resident's attending physician if a resident showed signs of hypothermia or hyperthermia. The plan indicated that signs of hyperthermia were "extremely high fever manifested by: fainting, vomiting, dizziness, palpitations, rapid pulse." The facility's plan included the intervention that if the facility was not "capable of operating the heating, ventilation, and air conditioning systems, the facility will supply fans and space heaters as needed." The facility's plan also indicated, "When the facility temperature is outside the acceptable range for a prolonged period of time, the facility will evaluate the situation, monitor residents and take appropriate actions to ensure the health and maximize the comfort of the residents." The plan did not define "prolonged period."

On 07/22/06, according to LVN 1 (interviewed on 08/17/06 at 3:00 p.m.), who was working at the Center Nurses Station at approximately 8:00 p.m., the temperature in the building was beginning to feel warm so she called the Maintenance Supervisor to inform him about the temperature. LVN 1 indicated that she was unable to determine the actual temperature in the building because she did not have a thermometer; however she revealed that she was sweating due to the increased temperature. LVN 1 indicated that the residents were warm. LVN 1 also stated that due to the increased temperature she instructed the Certified Nursing Assistants (CNAs) to remove the resident's blankets.

On 07/22/06, according to Resident D (interviewed on 07/31/06 at approximately 8:45 a.m.), the resident indicated that "I wasn't hot but I have a door." Resident D was in room 9C, which is located on the North Hall. Resident D's bed was positioned next to a sliding patio door. Resident D indicated that he could go outside and sit. Resident D also revealed "I was sweating but was OK outside." Resident D's diagnosis included chronic obstructive pulmonary disease (difficulty breathing). A quarterly MDS dated 06/01/06 indicated that Resident D had no memory problems or communication difficulties. Resident D's room was in the same section of the building as Resident A.

The DON was interviewed on 08/21/06 at 9:30 a.m. She indicated that the facility only had approximately six fans to distribute to residents. The DON also indicated that some residents had their own fans. The DON was unable to state which resident had fans (either a facility fan or their own fan).

EMT 2 was interviewed by telephone on 08/25/06 at 2:52 p.m. EMT 2 indicated that when the EMTs entered the facility (at 10:41 per Prehospital Care Report) it was "hot enough (in the facility) that I commented to my partner that it was hot." EMT 2 also indicated that she started sweating almost immediately. EMT 2 was asked if she observed any fans in the facility. EMT 2 indicated that the only fan she noticed was the one at the nurse's station (Resident A was in room 5B, which is located in North Hall-the EMTs would have passed a Nursing Station on the Center Hall and a Nurse's Station on North Hall). EMT 2 revealed that the facility called in Resident A's condition as a Code 2, which is without lights and sirens. However after entering Resident A's room and observing the resident, EMT 2 indicated it was clear that the resident was not doing well. EMT 2 stated that they prepared the resident for transport quickly and that as they were leaving the facility she told her partner that she was going to have to intubate (tube placed into the lung area to facilitate breathing) the resident. EMT 2 continued that as soon as the resident was loaded into the ambulance that they called for back up from the Stockton Fire Department and as soon as the fire department got there two firemen got into the ambulance to assist with CPR and they left the facility in a Code 3 situation (lights and sirens).

Due to Resident A's and another facility resident (Resident B's) condition upon arrival at the emergency room two police officers were dispatched to the facility to conduct "welfare checks" on the residents. The police incident report dated 07/23/06 indicated the following: "We arrived on scene at 0302 hours (3:02 a.m.)...When I walked into the facility I noticed the temperature in the building was very hot. The air seemed warm and muggy. I began sweating heavily after being in the building for approximately 15 minutes. I noticed the thermostat in the lobby read approximately 85 degrees." The police department's incident report contained statements made by some of the nursing staff regarding the temperature in the facility:

> CNA 1 stated that she worked a double shift on 07/22/06 from 2:40 p.m. to 7:00 a.m. (07/23/06) on the South Station and that in the afternoon as the outside temperature rose, the temperature inside the facility also increased. CNA 1 indicated that by the afternoon the air conditioner was blowing warm air throughout the facility. > CNA 2 said she began her shift on 07/22/06 at approximately 2:30 p.m. CNA 2 indicated that "Last night the air conditioning went out and the entire building was very warm when she arrived at work. Upon arrival at work she observed (Resident A) being treated by other staff members. (Resident A's) room was #5B...(Resident A) was then taken to a hospital." CNA 2 indicated that she had just returned to work after having a few days off and that she did not notice anything unusual with the facility's temperature when she last worked, however the day she returned to work (07/22/06) "the entire building was warm." CNA 2 also stated that, "Several of the patients complained of the heat. The staff members removed covers from the patients, opened doors, and made sure each patient had plenty of liquids. Fans were placed in several of the rooms; however, they did not have enough fans to go around for each room." > LVN 2 said she began her shift on 07/22/06 at 11:00 p.m. LVN 2 said when she arrived to work the temperature in the facility seemed warmer than usual. > CNA 3 indicated she began her shift at 10:30 p.m. on 07/22/06. She stated she worked the South Nurses Station (Rooms 30-35). CNA 3 reported that when she began her shift it was hot inside the building and that the air conditioner was not working because it was hotter than normal. CNA 3 indicated that her coworkers were also complaining about the heat. CNA 3 also stated that, "She was checking on her patients every fifteen minutes and every time she would walk into the rooms she could feel warm air blowing out of the vents."

According to the Maintenance Supervisor (interviewed on 08/07/06 at 10:45 a.m.) he was called back to the facility and arrived at approximately 3:30 a.m. The Maintenance Supervisor indicated that the air conditioning unit was not working when he arrived. He again attempted to reset the air conditioning unit as he had done earlier in the evening, however this time he was unsuccessful in getting the unit to restart. The Maintenance Supervisor stated at that point he could only call the air conditioning company to come look at the air conditioning unit because he was not able to do anything else.

The Stockton Fire Department was also dispatched to the facility. An interview was conducted with an administrative fire department staff member on 08/22/06 at 9:36 a.m. regarding the incident at the facility on 07/23/06. The interview revealed that the fire department took temperature readings inside the facility at approximately 3:00 a.m. using a thermo-imaging device and the temperature inside the facility was determined to be 87 degrees Fahrenheit (F). The administrative fire department staff member stated that the fire department personnel were trying to determine if the facility was safe in regards to "sheltering in place" or if an evacuation of the facility was necessary. The administrative fire department staff member stated he telephoned a physician at the local emergency department. A discussion regarding the current temperatures inside the facility, the projected daytime temperature, and the age of the residents at the facility occurred and it was determined that the facility was not safe for the resident's to remain in the facility, therefore an evacuation of the facility began at approximately 4:30 a.m.

According to wunderground.com accessed on 11/16/06, outside temperatures for the Stockton area on 07/22/06 ranged from a maximum temperature of 113 degrees F to a minimum temperature of 80 degrees F and on 07/23/06 a range from a maximum temperature of 115 degrees F to a minimum of 82 degrees F was recorded.

Resident A's ER record revealed that she arrived at the ER at 11:09 p.m. in cardiac arrest with CPR in progress. The ER physician's documentation indicated that at 11:23 p.m. CPR was discontinued and the resident was pronounced deceased.

The Coroner's Autopsy Report dated 10/06/06 revealed that the inspections findings were:

"1. Medical history of sudden onset of dyspnea (shortness of breath, difficulty and or labored breathing); taken emergently to the hospital A. The nursing home where she resided had an air-conditioner failure and was not repaired for many hours B. The indoor temperatures were quite high per reports of emergency and nursing personnel C. Another patient from the nursing home was also taken emergently to the hospital and also had documented elevated body temperature and was diagnosed as having hyperthermia D. Out door temperatures were also high..."

The Coroner's Autopsy Report indicated that the "cause of death was hyperthermia due to high environmental temperatures contributory hypertension (high blood pressure); congestive heart failure."

An interview was conducted on 04/25/07 at 1:10 p.m. with Resident A's family member. The family member stated that she visited Resident A on 07/21/06 and that the building seemed hot but she (the family member) worked outside so she just thought it was her. The family member indicated that Resident A had been in poor health for some time, however "she should have never had to die like that." The family member further indicated, "She (Resident A) died because of the heat. People (the facility staff) should have been more prepared."

The facility failed to provide Resident A with the necessary care and services to attain or maintain her highest practicable physical well being when they failed to:

1. Provide Resident A with safe room temperatures when the facility's air Conditioning unit malfunctioned on 07/22/06 during an area heat wave. 2. Follow the facility's undated policy "Dangerous Temperature Level" emergency action plan, which addressed measures the facility should have provided during times of increased heat.

These failures resulted in Resident A becoming short of breath and requiring emergency transportation to the general acute care hospital (GACH) on 07/22/06 where, on arrival to the emergency room (ER), Resident A was in full cardiac arrest with CPR (Cardiac Pulmonary Resuscitation) being preformed. CPR was unsuccessful and the resident was pronounced deceased. An autopsy subsequently determined the cause of death to be hyperthermia due to high environmental temperatures.

The Department determined the above violations presented imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was a direct proximate cause of the death of the patient.